Walsingham House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement. This meant the management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of the legal regulation in relation to governance of the service.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The registered manager and staff team promoted a culture at the service which was focused on providing good care and outcomes for people. Staff described good team working relationships and felt they understood what the aims of the provider were; to provide a good quality of life to the people they supported.

The provider had compassionate and inclusive leaders, however, they did not always have the skills, knowledge and experience required to ensure robust systems and processes were in place to provide effective oversight of the service. For example, during our inspection visit we found some medicines had not been managed or stored safely.

People living at the home were positive about the registered manager, and staff felt the registered manager was approachable and listened to them. Relatives gave positive feedback to us about the managers of the service.

The provider fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff were positive about the registered manager and told us they could always phone them if needed and gave us examples of when they had done so. One staff member told us, “There was an incident last night and we had to tell the manager, and they are coming in today to sort it out.” Staff felt any concerns they raised were listened to and acted on. Staff understood the importance of protecting people they supported from risks of harm and knew who to contact if needed.

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them. Staff felt fairly treated and were able to request reasonable adjustments in the workplace if needed.

The provider did not always have embedded systems of good governance. They did not always ensure they gained relevant information to mitigate potential risks. Processes used did not always promptly identify where improvements were needed. The registered manager had not always followed legal requirements or safe practices.

Some systems and processes were in place to check the safety and quality of the service. However, these were not always effective. A medicines audit had failed to identify that counter (second) signatures were not always recorded for medicines requiring additional controls. For example, we saw an entry that read ‘agency’ but no staff name or signature when this medicine had been administered to a person.

Where the registered manager had removed a quantity of medicines subject to specific legal requirements, checks had failed to identify there was no counter signature and no audit trail as to what had happened to the medicines. We found a quantity of medicines had been removed from the care home, kept longer than legally required and insecurely stored. This was unsafe practice and did not meet the legal requirements. We discussed this with the registered manager, who reflected they had made an error of judgement and breached their own policy on the safe administration, handling and disposal of medicines. During our inspection, we asked the registered manager to take immediate action to ensure the safe disposal of the medicines, which they did.

The registered manager, who was also the nominated individual, had delegated some checks to other staff members. The nominated individual is responsible for supervising the management of the service on behalf of the provider. We found these delegated checks were not always effective in identifying where improvements were needed. For example, infection prevention and control checks had not identified the issues we found.

Some checks were not in place. For example, no checks were made by the provider to ensure staff who drove the home’s vehicle had valid driving licences. The registered manager told us this check would be implemented.

We found gaps in information in all 3 staff files reviewed. There was no effective system in place to audit staff employment records to ensure they contained all the information required. The registered manager assured us checks would be put into place and actions taken where needed to address shortfalls.

We discussed the importance of checking both new staff’s skills, and long- term staff’s skills, to ensure practices reflected safe and best practice. The registered manager confirmed there was no effective system in place for competency checks to be carried out on staff.

The lack of oversight by the registered manager meant governance of the service needed improvement. The service was in breach of legal regulation in relation to good governance.

Following our feedback to the registered manager, they told us, that in hindsight, they recognised gaps in the management of Walsingham House. They explained the home manager was on a period of extended leave, the home had no senior care staff, and they (the registered manager) did care shifts at the home, but this was not the same as effective managerial oversight. The registered manager shared a plan of action with us which would address gaps in oversight.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Relatives were sent a questionnaire giving them the opportunity to share their views. No negative comments had been received.

Staff understood the importance of working with healthcare professionals and following their guidance. For example, where 1 person had dietary needs around the consistency of their food, staff told us if the person was struggling to swallow, they would contact the speech and language therapist for a review.

The provider did not always focus on continuous learning, innovation and improvement across the organisation and local system.

There had been some missed opportunities to learn and improve the service. At our last inspection of Walsingham House we had identified to the provider that checks and audits did not always identify where improvements were needed.

At this inspection we found the same. Whilst there was no evidence of any harm to anyone living at the service, the registered manager agreed with feedback we shared on the areas for improvement needed. Learning across the organisation had not taken place from a recent inspection of one of the provider’s other care homes, where it had been identified that the provider did not have embedded systems of good governance. The registered manager was committed to delivering good care and recognised that further systems needed to be implemented to improve on and record safety and quality checks. For example, the registered manager told us they would implement a system of staff working in the provider’s other services would no longer carry out checks in the service they worked in, but in other services giving ‘fresh eyes’ and identifying where improvements were needed.